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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181497 Inspection Date <br /> 05/28/24 <br /> Facility Name SRH GAS <br /> Facility Address City ZIP Code <br /> 749 E MARTIN LUTHER KING JR BLVD STOCKTON 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> NOR-CAL TANK TESTING 209-712-6366 <br /> Mailing Address 877 BATEMAN WAY GALT CA 95632 <br /> Service Technician Performing Inspection David Winkler <br /> Contractor/Tank Tester License Number 08_1739 Ex.2/28/26 <br /> ICC Number8883059-UT <br /> Expiration Date <br /> 01/30/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW 104-633 03/10/26 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW FLAPPERS <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> I hereby certify that the OPE was inspected in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br /> documentation is attached, and all information contained herein is accurate. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Ccrvir-c Tcr-hnirrinn Cinnnfi irc Date Total # of Pages <br /> w05/28/24 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />